Man hanged himself in Thorpe St Andrew mental health hospital after delays to find him a place to live, inquest told
06:30 28 February 2014
A devastated mother whose son was found hanged in a mental health hospital sobbed as she told of her love for him.
Siavash Amir-Hosseny, 26, was desperate to be released from the medium secure Norvic Clinic, in Yarmouth Road, Thorpe St Andrew, a jury inquest heard yesterday.
His psychiatrist Dr Trevor Broughton said he was well enough to live in supported accommodation, but the message was not relayed to his family and the local authority did not find suitable accommodation.
The Iranian refugee had fled his home country with his mother Masoumeh Khalaj in 2000 after his father was executed for political activism.
Mr Amir-Hosseny was “frustrated” that accommodation could not be found, and feared an incident the day before his death - when he made threats to kill and was told police would be involved - had affected his chances of release.
He was found hanged with his own bedsheets on May 6, 2012, having been detained at the clinic for around eight months.
A jury reached a majority verdict of seven to one that Mr Amir-Hosseny had taken his own life while the balance of his mind was disturbed.
He was first diagnosed as bipolar in 2007, but was recovering by the time of his death.
His mother spoke to him on the phone an hour before he died.
Speaking through a Farsi interpreter, she told the second day of the jury inquest: “He said ‘Mummy, I don’t think I’m going to get out of here as they reported to the police that I was upset and angry’.
“I told him I’m coming here tomorrow. I will get you released.”
Psychiatrists had recommended that Mr Amir-Hosseny be observed 12 times per hour after the incident on May 5, but this was not communicated to clinical staff.
Concern was also voiced over verbal handover of patient information between day and night shifts.
Leah Mallick, the mother of Mr Amir-Hosseny’s daughter, said a relationship that he had with an unqualified female member of staff at the Norvic Clinic may have affected his state of mind.
Dr Broughton said Mr Amir-Hosseny had not talked about the relationship, and the member of staff left the trust before disciplinary action could be taken.
Speaking after the inquest, Ms Mallick said she was “puzzled” by the verdict and that Mr Amir-Hosseny’s mother still wanted answers.
The Norfolk and Suffolk NHS Foundation Trust has changed its handover policy in light of Mr Amir-Hosseny’s death, and conducted its own internal investigation and commissioned an independent investigation.
Dr Jane Sayer, director of nursing, quality and patient safety at the trust, said: “We have already implemented every single one of the reports’ recommendations and all have now been completed.
“The coroner has acknowledged the commitment of our senior management to continue improvements and I will ensure the lessons of this tragedy are not forgotten.”
She extended her sympathies to the family.
Norfolk coroner Jacqueline Lake said she would not be compiling a report as the trust had completed its own.